Fatherhood Workshop Registration 2011-2012

 

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1. Please give us your information.

Please give us your information.   Attendee #1 (First & Last):
Attendee #2 (Spouse or partner, if coming):
Address:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP/Postal Code:
Email Address:
Phone Number:

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2. Though all of our dates have not yet been set, please indicate the month that would be best for you to attend our 8-hour workshop: Friday night 6:00pm to 9:00pm AND Saturday 9:00am to 3:00pm (Box lunch provided for you on Saturday).

Though all of our dates have not yet been set, please indicate the month that would be best for you to attend our 8-hour workshop: Friday night 6:00pm to 9:00pm AND Saturday 9:00am to 3:00pm (Box lunch provided for you on Saturday).   February 17 & 18, 2012 (Completed! Very successful!) March 16 & 17, 2012 (Vancouver Church of Christ, off I-205 on Padden Pkwy.) March 30 & 31, 2012 (Newberg Christian Church, 2315 Villa Road Newberg, OR 97132) April 20 & 21, 2012 (Location TBD) May 11 & 12, 2012 (Location TBD) June 15 & 16, 2012 (Location TBD)

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3. How did you hear about this workshop? (Please check all that apply.)

How did you hear about this workshop? (Please check all that apply.)   TV, Radio ad The Northwest Marriage Institute's website Monthly newsletter Email from a friend or colleague Email from other source Referred by a friend Referred by a minister, counselor, other professional Other

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4. Once we receive your information we will send an email confirmation that will indicate that you have been registered and a space in one of the 8-hour workshops is reserved. We will also be contacting you between now and your workshop to schedule a time for you to come to our Hazel Dell offices for the Workforce and Finances sessions. Feel free to contact us at 360-260-1100 for more information.

Once we receive your information we will send an email confirmation that will indicate that you have been registered and a space in one of the 8-hour workshops is reserved. We will also be contacting you between now and your workshop to schedule a time for you to come to our Hazel Dell offices for the Workforce and Finances sessions. Feel free to contact us at 360-260-1100 for more information.   I understand that the Northwest Marriage Institute will be contacting me soon.

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5. When would be the most convenient time for you to schedule your coaching sessions? (Please check all that apply.)

When would be the most convenient time for you to schedule your coaching sessions? (Please check all that apply.)   Weekday morning Weekday afternoon Weekday evening Saturday morning Saturday afternoon Sunday afternoon

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6. Would you prefer to meet with our Fatherhood coach alone or in a group setting with several other participants?

Would you prefer to meet with our Fatherhood coach alone or in a group setting with several other participants?   Group setting with other participants Private setting I have no preference. Either way is fine.

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7. Please check the box below indicating that you have read and understand the following statement:

Voluntary Assurance. By attending this Fatherhood & Relationships program, we understand that our attendance is strictly voluntary. We may elect to participate or not participate in any activity during the sessions. We also understand that we are not obligated to finish all sessions of the workshop or to participate in pre and post workshop surveys.

Please check the box below indicating that you have read and understand the following statement: Voluntary Assurance. By attending this Fatherhood & Relationships program, we understand that our attendance is strictly voluntary. We may elect to participate or not participate in any activity during the sessions. We also understand that we are not obligated to finish all sessions of the workshop or to participate in pre and post workshop surveys.   Attendee #1- I understand the Voluntary Assurance disclosure Attendee #2- I understand the Voluntary Assurance disclosure

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8. Please check the box below indicating that you have read and understand the following statement:

No Religious Content. We understand that this program is offered as part of a grant that the Northwest Marriage Institute received from the US Department of Health and Human Services. Since federal money is involved, we understand that there will be no religious discussion in the sessions. Although Dr. Whiddon is willing and able to answer religious questions, we understand that such religious discussions regarding the various issues of Fatherhood & Relationships must take place at a different place or time than the scheduled workshop sessions.

Please check the box below indicating that you have read and understand the following statement: No Religious Content. We understand that this program is offered as part of a grant that the Northwest Marriage Institute received from the US Department of Health and Human Services. Since federal money is involved, we understand that there will be no religious discussion in the sessions. Although Dr. Whiddon is willing and able to answer religious questions, we understand that such religious discussions regarding the various issues of Fatherhood & Relationships must take place at a different place or time than the scheduled workshop sessions.   Attendee #1- I understand the No Religious Content disclosure Attendee #2- I understand the No Religious Content disclosure

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9. Please check the box below indicating that you have read and understand the following statement:

Pre and Post Workshop Surveys. We understand that this Fatherhood & Relationships program is part of a national effort to help determine what works best in increasing the health of families in America. For this reason, we are being asked to fill out a pre-workshop survey, and to fill out a subsequent survey on the three-month anniversary of our workshop attendance. Statistical information will be shared with a national data-base. However, our personal information, including our names will not be shared with anyone outside of the Northwest Marriage Institute.

Please check the box below indicating that you have read and understand the following statement: Pre and Post Workshop Surveys. We understand that this Fatherhood & Relationships program is part of a national effort to help determine what works best in increasing the health of families in America. For this reason, we are being asked to fill out a pre-workshop survey, and to fill out a subsequent survey on the three-month anniversary of our workshop attendance. Statistical information will be shared with a national data-base. However, our personal information, including our names will not be shared with anyone outside of the Northwest Marriage Institute.   Attendee #1- I understand the Pre and Post Workshop Surveys disclosure Attendee #2- I understand the Pre and Post Workshop Surveys disclosure